Anatomy of the ankle ligaments: A pictorial essay

Abstract

Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.

Full text

ANKLE
Anatomy of the ankle ligaments: a pictorial essay
Pau Golano
´•Jordi Vega •Peter A. J. de Leeuw •
Francesc Malagelada •M. Cristina Manzanares •
Vı
´ctor Go
¨tzens •C. Niek van Dijk
Received: 13 February 2010 / Accepted: 16 February 2010 / Published online: 23 March 2010
ÓThe Author(s) 2010. This article is published with open access at Springerlink.com
Abstract Understanding the anatomy of the ankle liga-
ments is important for correct diagnosis and treatment.
Ankle ligament injury is the most frequent cause of acute
ankle pain. Chronic ankle pain often finds its cause in
laxity of one of the ankle ligaments. In this pictorial essay,
the ligaments around the ankle are grouped, depending on
their anatomic orientation, and each of the ankle ligaments
is discussed in detail.
Keywords Ankle anatomy Lateral collateral ligament 
Medial collateral ligament Ankle impingement 
Ankle sprain
Introduction
Despite the fact that the ankle ligaments are prone to injury
during the fast majority of sports, literature focusing on the
ankle ligaments is rare. Proper anatomic knowledge of the
different ligaments is important for a correct diagnosis and
subsequent treatment.
The most common mechanism of injury to the ankle
ligaments is inversion of the foot [4,33]. With this
mechanism of injury, the anterior talofibular ligament is the
first or only ligament to sustain injury [43]. A total rupture
involves the calcaneofibular ligament and the posterior
talofibular ligaments as well [9]. An eversion injury will
P. Golano
´(&)
Laboratory of Arthroscopic and Surgical Anatomy,
Department of Pathology and Experimental Therapeutics
(Human Anatomy Unit), University of Barcelona,
c/Feixa Llarga s/n (Campus Bellvitge),
08907 L’Hospitalet de Llobregat, Barcelona, Spain
e-mail: pgolano@ub.edu
M. C. Manzanares V. Go
¨tzens
Department of Pathology and Experimental Therapeutics
(Human Anatomy Unit), University of Barcelona,
c/Feixa Llarga s/n (Campus Bellvitge),
08907 L’Hospitalet de Llobregat, Barcelona, Spain
e-mail: mcmanzanares@ub.edu
V. Go
¨tzens
e-mail: vgotzens@ub.edu
J. Vega
Department of Orthopedic and Trauma Surgery,
Hospital Asepeyo San Cugat,
Avenida Alcalde Barnils 54-56,
08174 San Cugat del Valle
`s, Barcelona, Spain
e-mail: jordivega@hotmail.com
P. A. J. de Leeuw C. N. van Dijk
Department of Orthopaedic Surgery,
Academic Medical Center, University of Amsterdam,
PO Box 22700, 1100 DE Amsterdam, The Netherlands
e-mail: p.a.deleeuw@amc.uva.nl
C. N. van Dijk
e-mail: c.n.vandijk@amc.uva.nl
F. Malagelada
Department of Orthopedic and Trauma Surgery,
Hospital de Mataro
´, Carretera de Cirera s/n,
08304 Mataro
´, Barcelona, Spain
e-mail: fmalagelada@gmail.com
123
Knee Surg Sports Traumatol Arthrosc (2010) 18:557–569
DOI 10.1007/s00167-010-1100-x

cause damage to the deltoid ligaments [3], while a hyper-
dorsiflexion trauma might cause an injury to the syndes-
motic ligaments [11].
The ligaments around the ankle can be divided,
depending on their anatomic position, into three groups: the
lateral ligaments, the deltoid ligament on the medial side,
and the ligaments of the tibiofibular syndesmosis that join
the distal epiphyses of the bones of the leg (tibia and
fibula).
In this review article, these three groups of ligaments are
described separately, and in each section, the specific lig-
aments are described in detail.
The lateral and medial collateral ligaments
The lateral collateral ligament complex (LCL) consists of
the anterior talofibular, the calcaneofibular, and the pos-
terior talofibular ligaments. The medial collateral ligaments
(MCL), also known as the deltoid ligament, are a multi-
fascicular group of ligaments and can roughly be divided
into a superficial and deep group of fibers [8,24,28,36].
Fig. 1 Anterolateral view of the ankle. Anatomic dissection.
1Anterior talofibular ligament; 2anterior tibiofibular ligament;
3fibular insertion of the calcaneofibular ligament; 4superior extensor
retinaculum; 5inferior extensor retinaculum; 6peroneus tertius
tendon; 7extensor digitorum longus tendons; 8superior peroneal
retinaculum; 9inferior peroneal retinaculum; 10 peroneus brevis
tendon; 11 peroneus longus tendon; 12 extensor digitorum brevis
muscle
Fig. 2 Osteoarticular anatomic dissection of the lateral ligaments of
the foot and ankle joint. The anterior talofibular ligament is typically
composed of two separate bands. 1Tip of the lateral malleolus;
2tibia; 3anterior tibiofibular ligament; 4distal fascicle of the anterior
tibiofibular ligament; 5superior band of the anterior talofibular
ligament; 6inferior band of the anterior talofibular ligament; 7lateral
articular surface of the talus; 8neck of the talus; 9head of the talus;
10 calcaneofibular ligament; 11 talocalcaneal interosseous ligament;
12 cervical ligament; 13 talonavicular ligament; 14 navicular
Fig. 3 Anatomic dissection of the lateral region of the foot and ankle
showing the morphology and relationship of the anterior talofibular
with the calcaneofibular ligaments. 1Fibula and tip of the fibula;
2tibia (anterior tubercle with arrows); 3anterior tibiofibular
ligament; 4distal fascicle of the tibiofibular ligament; 5interosseous
membrane; 6foramen for the perforating branch of the peroneal
artery; 7talus;8anterior talofibularligament; 9calcaneofibular ligament;
10 talocalcaneal interosseous ligament; 11 inferior extensor retinaculum
(cut); 12 talonavicular ligament; 13 bifurcate ligament; 14 peroneal
tubercle (arrows showing the peroneal tendons sulcus); 15 peroneus
longus tendon; 16 peroneus brevis tendon; 17 calcaneal tendon
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Lateral collateral ligaments
Anterior talofibular ligament
The anterior talofibular ligament is the most frequently
injured ligament of the ankle and is the most frequently
observed injury in the emergency room [7] (Fig. 1). This
ligament plays an important role in limiting anterior dis-
placement of the talus and plantar flexion of the ankle
[40].
This ligament is closely related to the ankle joint capsule
and is typically composed of two separate bands [23]
(Fig. 2). The bands are separated by vascular branches
from the perforating peroneal artery and its anastomosis
with the lateral malleolar artery. In literature, numerous
anatomic descriptions have been given, varying from a
single up to three bands [9,10,12,23,24]; however, in our
observation during ankle dissections, this ligament most
commonly compromises a double-banded morphology,
similar to the description by Sarrafian [36].
The anterior talofibular ligament originates at the ante-
rior margin of the lateral malleolus. The center is on
average 10 mm proximal to the tip of the fibula as mea-
sured along the axis of the fibula [10]. The overall width
(6–10 mm) of the anterior tibiotalar ligament does not
appear to vary greatly irrespective of the number of bands
present, suggesting that the variations observed do not
modify the ligament’s function [40] (Figs. 3,4).
From its origin, it runs anteromedially to the insertion on
the talar body immediately anterior to the joint surface
occupied by the lateral malleolus. The ligament is virtually
horizontal to the ankle in the neutral position but inclines
upward in dorsiflexion and downward in plantar flexion. It
is only in the latter position that the ligament comes under
strain and is vulnerable to injury, particularly, when the
foot is inverted [9].
In plantar flexion, the inferior band of the ligament
remains relaxed while the upper band becomes taut. In
dorsiflexion, the upper band remains relaxed, and the
inferior band becomes tight.
Fig. 4 Anatomic dissection of the lateral ankle ligaments showing
the relationship of the calcaneofibular and lateral talocalcaneal
ligaments with the morphology of the anterior talofibular ligament.
Some authors describe a third band of the anterior talofibular
ligament. We have never found this third band in our dissections. In
the presented dissection, the superior band of the anterior talofibular
ligament is smaller than usually. 1Tip of the fibula; 2superior and
inferior bands of the anterior talofibular ligament; 3calcaneofibular
ligament; 4lateral talocalcaneal ligament; 5anterior tibiofibular
ligament; 6distal fascicle of the anterior tibiofibular ligament;
7triangular region of the talus; 8lateral articular surface of the talus;
9dorsal articular surface of the talus; 10 talocalcaneal interosse-
ous ligament; 11 cervical ligament; 12 talonavicular ligament;
13 navicular; 14 lateral calcaneocuboid ligament; 15 bifurcate
ligament (calcaneonavicular fascicle)
Fig. 5 Osteoarticular dissection of the calcaneofibular ligament
during ankle movements. aNeutral position. bDorsal flexion.
cPlantar flexion. Calcaneofibular ligament becomes horizontal during
plantar flexion and vertical in dorsal flexion, remaining tensed
throughout the entire arc of motion of the ankle. 1Calcaneofibular
ligament; 2tip of the fibula; 3calcaneus; 4peroneal tubercle;
5subtalar joint; 6anterior talofibular ligament; 7neck of the talus;
8talocalcaneal interosseous ligament; 9anterior tubercle of the tibia;
10 anterior tibiotalar ligament; 11 posterior tubercle of the tibia;
12 lateral talar process; 13 calcaneocuboid joint; 14 lateral calcane-
ocuboid ligament; 15 talonavicular ligament; 16 cervical ligament;
17 navicular; 18 bifurcate ligament (calcaneonavicular fascicle);
19 long plantar ligament
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Calcaneofibular ligament
The calcaneofibular ligament originates from the anterior
part of the lateral malleolus. It is anatomically positioned
just below the lower band of the anterior talofibular liga-
ment. Frequently, fibers connecting these ligaments can be
observed (Fig. 3). In the neutral ankle position, the liga-
ment runs obliquely downwards and backwards to attach to
the posterior region of the lateral calcaneal surface (Fig. 5).
This ligament is superficially crossed by the peroneal ten-
dons and sheaths, which can leave a concavity over the
ligament; only about 1 cm of the ligament is uncovered
(Fig. 6).
The anatomic variants of the calcaneofibular ligament
and their relationship with the lateral talocalcaneal liga-
ment have been the subject of study [39]. In 35% of the
cases, the calcaneofibular ligament is reinforced by the
lateral talocalcaneal ligament, attached by the former but
diverging proximally or distally. In 23% of the cases, a
lateral talocalcaneal ligament exists anteriorly and inde-
pendent of the calcaneofibular ligament. In 42% of the
cases, the lateral talocalcaneal is absent and is replaced by
an anterior talocalcaneal ligament. In these cases, the
calcaneofibular ligament acquires more functional signifi-
cance in providing stability to the subtalar joint [39]
(Fig. 7).
In cross-section, the ligament is rounded and has a
diameter of 6–8 mm, and its length is about 20 mm. This
ligament is separate from the ankle joint capsule, but it is
intimately associated with the posteromedial part of the
peroneal tendons sheath, covering almost the entire liga-
ment [36].
The calcaneofibular ligament is the only ligament
bridging both the talocrural joint and subtalar joint. Inser-
tion of this ligament and its axis of rotation point allow
flexion and extension movements of the talocrural joint.
Depending on its bi-articular characteristic, this ligament
also permits subtalar movement.
Brostro
¨m found that combined ruptures of the anterior
talofibular and the calcaneofibular ligaments occurred in
20% of cases and that isolated rupture of the calcaneofi-
bular ligament was very rare [9]. The posterior talofibular
ligament is usually not injured unless there is a frank dis-
location of the ankle.
Variants in its orientation of the calcaneofibular liga-
ment were studied by Ruth [35]. The calcaneofibular lig-
ament becomes horizontal during extension and vertical in
flexion, remaining tense throughout its entire arc of motion
(Fig. 5). A valgus or varus position of the talus consider-
ably changes the angle formed by the ligament and the
longitudinal axis of the fibula. The ligament is relaxed in
the valgus position and tense in the varus position. This
explains the potential for injury even without dorsiflexion-
plantar flexion movement in the ankle.
Posterior talofibular ligament
The posterior talofibular ligament originates from the
malleolar fossa, located on the medial surface of the lateral
malleolus, coursing almost horizontally to insert in the
posterolateral talus. In plantar flexion and in the neutral
ankle position, the ligament is relaxed, while in dorsiflex-
ion, the ligament is tensed. Due to the multifascicular
aspect of this ligament, it inserts not just in a specific area.
Fibers insert in the posterior surface of the talus, in the
Fig. 6 Anatomic dissection showing the relationship of the calc-
aneofibular ligament with peroneal tendons. 1Calcaneofibular
ligament; 2peroneus longus tendon; 3peroneus brevis tendon;
4fibula; 5talofibular ligament; 6calcaneus; 7subtalar joint; 8septum
in the peroneal tubercle; 9superior extensor retinaculum; 10 inferior
extensor retinaculum; 11 extensor digitorum longus tendons;
12 peroneus tertius tendon; 13 extensor digitorum brevis; 14 extensor
digitorum brevis tendon; 15 calcaneal tendon; 16 Kager’s fat pad;
17 tuberosity of the fifth metatarsal bone; 18 lateral plantar fascia;
19 abductor digiti minimi
Fig. 7 Osteoarticular dissection. Relationship of the calcaneofibular
ligament with the lateral talocalcaneal ligament. 1Calcaneofibular
ligament; 2lateral talocalcaneal ligament; 3anterior talofibular
ligament; 4peroneal tubercle
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lateral talar process or os trigonum, if present. Some fibers
can contribute in forming the tunnel for the flexor hallucis
longus tendon (Fig. 8).
Moreover, a group of fibers fuse with the posterior
intermalleolar ligament [29]. The posterior intermalleolar
ligament has been the subject of recent studies because of
its involvement in the posterior soft tissue impingement
syndrome of the ankle [17,27]. Its prevalence of occur-
rence both in radiological and in anatomic studies vary
widely, ranging from 19% up to 100% [24,27,30]. In our
dissections, the intermalleolar ligament is a consistent
finding [16].
In the recent study of Oh et al. [27] on the morphology
of the posterior intermalleolar ligament and its correlation
with MR images, the posterior intermalleolar ligament was
observed in 81.8% of the specimens (63 of 77 specimens).
In MRI study, the intermalleolar ligament was identified in
all ankles (26 specimens) (Figs. 9,10).
These differences can probably be explained by its
limited size and therefore difficult assessment during an
ankle dissection, although Oh et al. [27] propose the
number of specimens used or interracial variations. In
addition, the ligament may be divided into two or three
different bands (20% [34]–100% [27]).
In the posterior view, the posterior intermalleolar liga-
ment is situated between the transverse ligament and the
posterior talofibular ligament and runs obliquely from lat-
eral to medial and from downwards to upwards. The shape
of the posterior intermalleolar ligament is variable. These
variations depend on its medial arising sites, the number of
composing fiber bundles, and the degree of the bundle
compactness. The medial arising sites of the ligament
included the lateral border of the medial malleolar sulcus,
the medial border of the medial malleolar sulcus through
the septum between the flexor digitorum longus and pos-
terior tibial tendons, the posterior distal margin of the tibia,
and the posterior process of the talus through the joint
capsule [27] (Fig. 10). The posterior intermalleolar liga-
ment tenses during dorsiflexion and relaxes during plantar
flexion, and therefore, trauma that causes forced dorsi-
flexion of the ankle can be assumed to produce either injury
or rupture of this ligament, or osteochondral avulsion.
Plantar flexion would cause it to relax and become sus-
ceptible to trapping between the tibia and the talus, leading
to impingement (Fig. 11).
Since the introduction of the posterior ankle arthroscopy
by van Dijk et al. [44,45] in 2000, the posterior ankle
Fig. 8 Posterior view of the anatomic dissection of the ankle
ligaments. 1Tip of the fibula; 2peroneal groove of the fibula;
3tibia; 4superficial component of the posterior tibiofibular ligament;
5deep component of the posterior tibiofibular ligament or transverse
ligament; 6posterior calcaneofibular ligament; 7lateral talar process;
8medial talar process; 9tunnel for flexor hallucis longus tendon;
10 flexor hallucis longus retinaculum; 11 calcaneofibular ligament;
12 subtalar joint; 13 posterior intermalleolar ligament; 14 flexor
digitorum longus tendon (cut); 15 tibialis posterior tendon; 16 peroneal
tendons
Fig. 9 a Posterior view of the ankle ligaments showing the relation-
ships of the posterior intermalleolar ligament, posterior talofibular
ligament and transverse ligament. bT1-weighted spin-echo MR
imaging showing the correlation between MRI and the saggital cuts in
a.1Posterior intermalleolar ligament; 2superficial component of the
tibiofibular ligament; 3deep component of the tibiofibular ligament or
transverse ligament; 4posterior talofibular ligament; 5lateral talar
process; 6tunnel for flexor hallucis longus tendon
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ligaments can clearly be visualized and treated in case of
pathology.
Medial collateral ligament
The anatomical descriptions of the MCL vary widely in the
literature; however, in general most agree that it is com-
posed of two layers; the superficial and deep [8,24,28,36].
Similar to the posterior talofibular ligament, the MCL is a
multifascicular ligament, originating from the medial
malleolus to insert in the talus, calcaneus, and navicular
bone.
The tendon sheath of the posterior tibial muscle covers
the posterior and middle part of the deltoid ligament in
much the same way as the peroneal tendon sheath is
associated with the calcaneofibular ligament on the lateral
side.
The most commonly accepted description of the MCL is
the one originally proposed by Milner and Soames [24].
Six bands or components have been described for the
MCL: three of them are always present (the tibiospring
ligament, tibionavicular ligament, and deep posterior tibi-
otalar ligament), whereas the presence of the other three
may vary (superficial posterior tibiotalar ligament, tibio-
calcaneal ligament, and deep anterior tibiotalar ligament)
[8,24] (Table 1; Figs. 12,13). Most of the MCL is covered
by tendons as it extends down the leg to the bony insertions
in the foot (Fig. 14).
Although the description proposed by Milner and Soa-
mes has been accepted [24], the anatomy of this ligament
and its components is still confusing. During our dissec-
tions, we found it rather difficult to determine each indi-
vidual band, since most are continuous to one another, and
therefore pointing out individual bands is artificial.
Ligaments that join the distal epiphyses
of the tibia and fibula
The talocrural joint consists of a fork-shaped dome
formed by the distal tibia and fibula and the talar trochlea
enclosed by this mortise. Cartilagenous areas of the ankle
joint are not congruent in their surface outlines. In the
frontal plane, the talar dome has a slightly concave pro-
file. The planes of the tibial and fibular facets are not
parallel. The trochlea is wider anteriorly than posteriorly,
and the cartilage covered surfaces have slightly curved
sides. The fibular facet has a convex contour, whereas the
tibial facet is concave [13].
It is a syndesmotic articulation that allows the tibia-
fibula as a whole to adapt to the varying width of the upper
articular surface of the talus by slight ascending and medial
rotation movements of the fibula during extreme dorsi-
flexion (maximum width) and by inverse movements dur-
ing plantar flexion (minimum width) [21].
The syndesmotic ligament complex ensures the stability
between the distal tibia and the fibula and resists the axial,
rotational, and translational forces that attempt to separate
the tibia and fibula. The three ligaments responsible are the
anterior or anteroinferior tibiofibular ligament, the poster-
ior or posteroinferior tibiofibular ligament, and the
Fig. 10 Posterior view of the anatomic dissection of the ankle
ligaments showing the posterior intermalleolar ligament with its
relation to the surrounding anatomy. 1Fibula; 2tip of the fibula;
3peroneal groove of the fibula; 4tibia; 5posterior tubercle of the
tibia; 6superficial component of the posterior tibiofibular ligament;
7deep component of the posterior tibiofibular ligament or transverse
ligament; 8interosseous membrane; 9posterior talofibular ligament;
10 lateral talar process; 11 tunnel for flexor hallucis longus tendon;
12 flexor hallucis longus retinaculum; 13 calcaneofibular ligament;
14 subtalar joint; 15 flexor digitorum longus tendon (cut); 16 tibialis
posterior tendon (cut); 17 posterior intermalleolar ligament: ATibial
insertion (tibial slip in arthroscopic view). BTalar insertion (lateral
talar process). CTibial malleolar insertion through the septum
between the flexor digitorum longus and posterior tibial tendons.
DTalar insertion (medial talar process) through the joint capsule
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interosseous tibiofibular ligament. The inferior segment of
the interosseous membrane also helps stabilize the tibio-
fibular syndesmosis. Distal to the insertion site of this
ligament, the remaining anterior surface corresponds to the
tibiofibular synovial recess of the ankle joint, and at the
posterior surface, there is a small bundle of adipose tissue
called the fatty synovial fringe (Fig. 15). The synovial
fringe lowers or rises during ankle movements, retracting
in dorsiflexion to rise and position itself between the tibia
and fibula and descending in plantar flexion toward the
ankle joint. This structure has been implicated as a cause of
chronic pain following ankle sprain in the condition known
as anterolateral soft tissue impingement or more specifi-
cally, syndesmotic impingement.
Anterior or anteroinferior tibiofibular ligament
The ligament originates in the anterior tubercle of the tibia
(5 mm in average above the articular surface [41]), and its
fibers extend in a distal and lateral direction to the insertion
site in the anterior margin of the lateral malleolus, with
increased length of the fibers distally. Upon examination,
the ligament is seen to be divided into several fascicles,
allowing the perforation branches from the peroneal artery
(Figs. 16,17). The most distal fibers of the ligament at its
origin may be confused with those of the anterior talofib-
ular ligament [1,6,36].
The most distal fascicle of the anterior tibiofibular
ligament appears to be independent from the rest of the
Fig. 11 Anatomic view of the posterior intermalleolar ligament
(arrows) showing its involvement in the posterior soft tissue
impingement of the ankle. From dorsiflexion (a) to plantar flexion
(d), to dorsiflexion (f). 1Superficial component of the posterior
tibiofibular ligament; 2deep component of the posterior tibiofibular
ligament or transverse ligament; 3posterior talofibular ligament; 4
lateral talar process; 5medial talar process; 6tunnel for the flexor
hallucis longus tendon; 7deep layer of the medial collateral ligament
(deep posterior tibiotalar ligament)
Table 1 Comparison of the
nomenclature used for the
medial collateral components,
as suggested by Sarrafian [36]
and Milner and Soames [24]
Milner and Soames [24] Sarrafian [36]
Superficial layer
Tibiospring ligament (major component) Tibioligamentous fascicle
Tibionavicular ligament (major component) Tibionavicular fascicle and anterior
superficial tibiotalar fascicle
Superficial tibiotalar ligament (additional band) Superficial posterior tibiotalar ligament
Tibiocalcaneal ligament (additional band) Tibiocalcaneal ligament
Deep layer
Deep posterior tibiotalar ligament (major component) Deep posterior tibiotalar ligament
Anterior deep tibiotalar ligament (additional band) Deep anterior tibiotalar ligament
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structure (Fig. 16). It is separated by a septum of fibro-
adipose tissue and may be slightly deeper than the rest
of the ligament. Pathology to this fascicle is frequently
described as being responsible for anterolateral soft tis-
sue impingement [1,2,5,32]. Excision of this distal
fascicle through open or ankle arthroscopic approach
frequently resolves the patient’s complaints, whereas the
ankle stability is not comprised [6,25,26,31].
Impingement of the distal fascicle of the anterior tib-
iofibular ligament appears to depend on changes in the
ankle mechanics [6]. An injury to the LCL (e.g., anterior
talofibular ligament) would increase anteroposterior laxity
of the ankle [20]. This, in turn, would result in increased
anterior extrusion of the talus and cause the distal fascicle
to have greater contact and pressure on the talus [6].
Another factor related to distal fascicle impingement is
the level at which the anterior tibiofibular ligament is
inserted in the fibula with respect to the joint line. More
distal insertion of the ligament could lead to increased
contact in the neutral position of the ankle and a higher
potential for ligamentous pathology (Fig. 18). Knowledge
of this configuration is important to understand the ana-
tomic bases for anterolateral soft tissue impingement,
since abrasion between the distal fascicle of the anterior
tibiofibular ligament and the talus may lead to pain
(Fig. 19).
Our observations in the dissection room have allowed us
to identify contact between the distal fascicle and the talus
in the neutral position. This finding is frequently observed
during ankle arthroscopy, and the surgeon should consider
it a normal feature [2]. This fact has been reported by other
authors [1,19,22,26,32], although in cases of anatomic
variation or ankle instability, the feature may be patho-
logical. Contact decreases with joint distraction [2], which
should be taken into account during arthroscopy. Akseki
et al. [2] observed that section of the anterior talofibular
ligament does not alter the contact when the ankle is in
neutral position, although important changes are observed
when the ankle is in movement. Therefore, ankle instability
is one direct factor in anterior tibiofibular ligament
pathology.
A diagnosis of this type of ligamentous impingement
should be considered in patients with chronic pain in the
anterolateral area of the ankle following a sprain, with joint
stability and a normal radiological appearance [14].
Posterior or posteroinferior tibiofibular ligament
As is frequently observed, also for this rather strong
compact syndesmotic ligament, numerous terminologies
have been postulated [5], which is particularly evident in
the arthroscopic literature [16].
This ligament is basically formed by two independent
components, the superficial and deep component
(Fig. 20).
Fig. 12 Schematic representation of the main components of the
medial collateral ligament found as frequently observed in our
dissections. The morphology of the medial malleolus is helpful to
understand the origins of the medial collateral ligament. In the medial
view, two areas or segments (culliculi) can be seen, separated by the
intercollicular groove. 1Tibionavicular ligament; 2tibiospring
ligament; 3tibiocalcaneal ligament; 4deep posterior tibiotalar
ligament; 5spring ligament complex (plantar and superomedial
calcaneonavicular ligaments); 6anterior culliculus; 7posterior
culliculus; 8intercullicular groove; 9sustentaculum tali; 10 medial
talar process; 11 lateral talar process; 12 navicular; 13 navicular
tuberosity
Fig. 13 Medial view of the anatomic dissection of the main
components of the medial collateral ligament. 1Tibionavicular
ligament; 2tibiospring ligament; 3tibiocalcaneal ligament; 4deep
posterior tibiotalar ligament; 5spring ligament complex (superome-
dial calcaneonavicular ligament); 6medial talar process; 7susten-
taculum tali; 8medial talocalcaneal ligament; 9tibialis posterior
tendon
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The superficial component originates at the posterior
edge of the lateral malleolus and directs proximally and
medially to insert in the posterior tibial tubercle. This
component would be homologous to the anterior tibiofib-
ular ligament. The term posterior or posteroinferior tibio-
fibular ligament is usually used to refer to the superficial
component (Figs. 20,21).
The deep component is cone shaped and originates in
the proximal area of the malleolar fossa to insert in the
posterior edge of the tibia. Its insertion is immediately
posterior to the cartilaginous covering of the inferior tibial
articular surface; the fibers may reach the medial malle-
olus (Fig. 21). This component is also known as the
transverse ligament, forming a true labrum [36] to provide
Fig. 14 Medial view of the anatomic dissection of the medial
collateral ligament. Most of the medial collateral ligament is covered
by tendons (tibialis posterior and flexor digitorum longus tendons). In
order to see the ligament, the tendon of flexor digitorum longus was
removed. aNeutral position showing the relationship with the tibialis
posterior tendon. bThe posterior tibialis tendon was removed.
cPlantar flexion. The components located anteriorly to the bimalleolar
axis are tensed. dDorsiflexion. The components located anteriorly to
the bimalleolar axis are relaxed. 1Medial malleolus; 2lateral talar
process; 3sustentaculum tali; 4navicular; 5tibialis posterior tendon; 6
navicular tuberosity; 7flexor hallucis longus (cut); 8flexor hallucis
longus retinaculum; 9posterior talocalcaneal ligament; 10 calcaneal
tendon (cut at the level of the insertion); 11 long plantar ligament;
12 spring ligament complex (superomedial calcaneonavicular liga-
ment); 13 tibionavicular ligament; 14 tibiospring ligament; 15 tibio-
calcaneal ligament; 16 deep posterior tibiotalar ligament
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talocrural joint stability and to prevent posterior talar
translation [37].
Interosseous tibiofibular ligament
The interosseous tibiofibular ligament is a dense mass of
short fibers, which, together with adipose tissue and small
branching vessels from the peroneal artery, span the tibia to
the fibula. It can be considered a distal continuation of the
interosseous membrane at the level of the tibiofibular
syndesmosis [18,36,38]. Some investigators have sug-
gested that the interosseous ligament is mechanically
insignificant, whereas others consider it the primary bond
between the tibia and fibula. Hoefnagels et al. [18] suggest
that the interosseous ligament plays an important role in the
stability of the ankle.
Fig. 15 Medial view of the tibiofibular joint (os talus previously
removed). 1Articular surface of the lateral malleolus; 2distal
articular surface of the tibia; 3anterior tibiofibular ligament (distal
fascicle); 4superficial component of the posterior tibiofibular
ligament; 5deep component of the posterior tibiofibular ligament or
transverse ligament; 6fatty synovial fringe; 7anterior talofibular
ligament; 8calcaneofibular ligament; 9posterior talofibular ligament;
10 fibulotalocalcaneal ligament or Rouvie
`re and Canela ligament
Fig. 16 Anterosuperior view of talocrural joint and dorsum of the
foot. 1Anterior tibiofibular ligament; 2anterior tubercle of the tibia
Fig. 17 Anatomic view of the anterolateral part of the ankle showing
the relationship between the anterior tibiofibular ligament and the
perforating branch of the peroneal artery (arteries are filled with black
latex). 1Anterior tibiofibular ligament; 2distal fascicle of the anterior
tibiofibular ligament; 3anterior tubercle of the tibia; 4perforating
branch of peroneal artery; 5triangular region of the talus; 6anterior
malleolar artery; 7lateral articular surface of the talus; 8dorsal
articular surface of the talus; 9anterior talofibular ligament
566 Knee Surg Sports Traumatol Arthrosc (2010) 18:557–569
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Conclusions
The ankle sprain injury is the most frequently observed
injury in the emergency room [7]. Up to 40% of individuals
with a history of an ankle ligament injury have been found
to have residual complaints interfering with daily living
[15,42]. Adequate knowledge of the anatomy of the ankle
ligaments provides a foundation for understanding the
basic mechanism of injury, diagnosis, and treatment of
these ankle sprains.
Soft tissue impingement syndromes of the ankle are
usually preceded by an ankle sprain. Depending on the
mechanism of injury, a specific ligament and/or ligaments
can be injured [43]. Injury to the anterior talofibular liga-
ment is the most common injury following an ankle sprain.
Most frequently, it is an isolated injury; however, in
approximately 20% of the patients, also the calcaneofibular
ligament is injured [9].
An inversion sprain can result in injury to the capsule,
lateral or medial collateral ligaments, or tibiofibular liga-
ments. The added influence of plantar or dorsiflexion on the
injury mechanism will mean that the lesion is predomi-
nantly anterior or posterior, respectively, and could also
lead to injury to other structures such as the posterior
intermalleolar ligament, the osteochondral region of the
neck of the talus, or the anteroinferior margin of the tibia.
The mechanism of foot eversion is more closely asso-
ciated with injury to the medial capsular and ligamentous
elements, although an inversion sprain can also produce a
lesion to these structures. Medial injury is probably more
influenced by the rotating component of the subtalar joint
to which the capsule and the MCL are subject.
The aim of this pictorial review on the anatomy of the
ankle ligaments is to provide a guide to those who are
involved in diagnosing and treating ligament injury around
the ankle.
Fig. 18 Anatomic view of the anterior ligaments of the ankle.
1Anterior tibiofibular ligament; 2distal fascicle of the anterior
tibiofibular ligament; 3tibia (anterior tubercle indicated with arrows);
4anterior talofibular ligament; 5beveled triangular region of the
talus; 6deep layer of the medial collateral ligament; 7superficial
layer of the medial collateral ligament; 8notch of Harty
Fig. 19 Osteoarticular anatomic dissection of the ligaments of the
foot and ankle joint. 1Tip of the lateral malleolus; 2tibia (anterior
tubercle indicated with arrows); 3anterior tibiofibular ligament;
4distal fascicle of the anterior tibiofibular ligament; 5imaging
showing a calcification in the tibial insertion of the distal fascicle of
the anterior tibiofibular ligament; 6abrasion of the joint cartilage in
the region where the anterior tibiofibular ligament came into contact
with the talus; 7beveled triangular region of the talus; 8anterior
talofibular ligament; 9calcaneofibular ligament; 10 lateral talocalca-
neal ligament; 11 cartilaginous rim; 12 talonavicular ligament;
13 lateral calcaneocuboid ligament; 14 navicular; 15 cervical
ligament; 16 lateral cuneiform; 17 dorsal cuboideonavicular ligament;
18 dorsal cuneonavicular ligament; 19 calcaneus (peroneal tubercle);
20 anterior tibialis tendon
Fig. 20 Anatomic dissection of the posterior ligaments of the ankle.
1Lateral malleolus; 2tip of the lateral malleolus; 3peroneal groove;
4tibia; 5posterior tubercle of the tibia; 6posterior tibiofibular
ligament, superficial component; 7posterior tibiofibular ligament,
deep component or transverse ligament; 8subtalar joint; 9posterior
talofibular ligament; 10 posterior intermalleolar ligament; 11 lateral
talar process; 12 tunnel for flexor hallucis longus tendon (tendon
was removed); 13 medial talar process; 14 calcaneofibular ligament;
15 flexor digitorum longus
Knee Surg Sports Traumatol Arthrosc (2010) 18:557–569 567
123

Acknowledgments No benefits in any form have been received or
will be received from a commercial party related directly or indirectly
to the subject of this review. No sources of funding were received to
assist in this review. The authors have no conflicts of interest that are
directly relevant to this review.
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
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